Book Review

Controversies in Managed Mental Health Care

N Engl J Med 1996; 335:1541-1542November 14, 1996

Article

Controversies in Managed Mental Health Care
Edited by Arthur Lazarus. 427 pp. Washington, D.C., American Psychiatric Press, 1996. $58.50. ISBN: 0-88048-115-3

There seems to be no aspect of [psychiatric] practice more fraught with rancor and contentiousness than that of managed care,” states Arthur Lazarus in the afterword to this book. As the editor, Lazarus poses critical questions on the relation between psychiatric practice and managed care as the titles of each chapter. There is little rancor or contentiousness in the book, nor even much controversy. Instead, most of the chapters provide excellent guidelines — almost a “guide to the perplexed,” one might say — for psychiatrists working in managed-care systems or planning to join one. Many of the book's sections could help any physician, since they offer methods of negotiating the complexities of a system that is constantly changing and expanding.

This book recognizes that many psychiatrists are unhappy and resentful about their role in managed-care programs and about how these systems treat them. A recent report by M. Schlesinger, R.A. Dorwart, and S.S. Epstein (American Journal of Psychiatry 1996;153(2):256–260) revealed that more than three fourths of the psychiatrists who responded to the survey had felt pressure from insurers to discharge patients early. Nearly two thirds reported that hospitals were limiting length of stay, and about half had been discouraged from treating severely ill patients who were uninsured or Medicaid recipients. The president of the American Psychiatric Association bitterly attacked managed care in his “Open Letter to President Clinton” in the August 2, 1996, issue of the association's Psychiatric News.

The book's 27 chapters vary in ideology and content, but the overall message is one of accommodation. What principal strategies and tactics do the authors advocate? Notably, the first chapter, by Fink, and the afterword, identify as the prime problem the emergence of nonmedical psychotherapists, a development that has caused serious apprehension and resentment among psychiatrists. Fink, Lazarus, and others in this book recommend accepting nonmedical personnel and recognize that in certain instances they can be as effective as psychiatrists and much cheaper. This implies a new role for psychiatrists in managed care and consequently a need to retrain them.

Chapter 17 deals with that retraining. Several authors assert that the psychiatrist's strength rests in part on the “biopsychosocial” model, since only the psychiatrist, who has training in all three elements of that model, can integrate them for the patient's benefit, particularly in regard to combining psychopharmacology with psychotherapy.

Many contributors think that psychiatrists are faced with a Hobson's choice, which the editor sums up as “adapt or fight back and risk being left out in the cold.” The hope is that managed care will improve relations with physicians in general and psychiatrists in particular by precisely stating policies, procedures, and clinical orientations. In chapter 8 (“How Is Resistance to Managed Care Manifested?”), the recommendations include counseling psychiatrists to be more understanding, less combative, ready to negotiate, and willing to cooperate with managed-care procedures. However, change will require not only the willingness of managed care to change but also the insistence of providers, consumers, and legislatures that it do so. Such a joint effort was successful in extending the duration of postpartum hospitalization.

The numerous other topics discussed include quality assurance, utilization review, outcome studies, ethics, and questions of hospitalization. Others are mentioned only briefly or are absent, such as studies of consumer reactions and the excessive compensation of certain executives of for-profit companies.

Two excellent chapters deserve mention. In chapter 23 (“Can Managed Competition Reform Mental Health Care?”) Stroup and Dorwart emphasize the trade-offs: “Managed competition is not a panacea for the ills of the mental health care system, nor is it an ominous plague.” They make the following prediction, which comes as a bit of a surprise: “We conjecture that an initial phase of health care reform will be based largely on managed competition and managed care plans, with a second phase 5–10 years later more closely resembling a single-payer plan.” The other chapter, by Mechanic (“Can Research on Managed Care Inform Practice and Policy Decisions?”), is a scholarly review of current research on managed care, including studies of outcome comparing managed care and fee-for-service practice.

Controversies in Managed Mental Health Care offers informative chapters on how a psychiatrist might negotiate the managed-care system in the United States, but anyone looking for articles at the cutting edge of conflict in managed care will be disappointed. The implication is that the time for opposition has passed and that new tactics and strategies must be adopted.

Alfred M. Freedman, M.D.
New York Medical College, Valhalla, NY 10595